Recovery from alcohol dependence: Do smoking indicators predict abstinence?

A narrative review of outcome measures used in drug and alcohol inpatient withdrawal treatment research

ISSUES

Assessing drug and alcohol inpatient withdrawal treatment programs is important, as these represent a first step of treatment among people with alcohol and drug problems. However, there are many ways of measuring outcomes making it difficult for service providers to decide which domains and methods to use. This narrative review aims to clarify frequencies of the domains and methods used to assess withdrawal treatment outcomes.

APPROACH

We reviewed published studies that examined outcomes of inpatient drug and alcohol withdrawal treatment. The types of outcome measures used and the frequency of use were summarised.

KEY FINDINGS

The review showed that assessment of withdrawal treatment outcomes goes beyond traditional abstinence measures. Outcomes mainly focus on biological and psychological outcomes, with social outcomes rarely measured. Even within outcome domains (e.g., cravings), there were many assessment methods.

IMPLICATIONS

The review provides service providers with an outline of common outcome domains and measures. Given the importance of social functioning to recovery from alcohol and drug problems, greater emphasis on such measures is desirable. Future research could develop greater consensus on outcome measures for use in withdrawal management services to facilitate clarity around factors associated with treatment success.

CONCLUSION

Outcome assessment in withdrawal treatment goes beyond abstinence to include holistic measurement of biological, psychological and some social outcomes; but more work needs to be done to cohere the different assessment methods and broaden the scope to include social functioning.

Smoking As an Outcome Moderator In the Treatment of Alcohol Use Disorders

AIMS

To clarify whether smoking interferes with successful treatment of alcohol use disorder (AUD).

METHODS

The current systematic review investigates the potential moderating effect of smoking on behavioural and pharmacological treatment of AUD. In addition, this review summarizes the results of randomized controlled trials investigating the effect of smoking cessation treatments in subjects with AUD on drinking outcomes.

RESULTS

Overall, the results show that 16 out of the 31 pharmacological and psychotherapeutic alcohol treatment studies showed that being a non-smoker or decreased tobacco consumption during AUD treatment is associated with beneficial drinking outcomes, including reduced drinking, later relapse and prolonged alcohol abstinence. As such, smoking predicts poorer drinking outcomes in alcohol treatments. In the stop-smoking studies in patients with AUD, reduced smoking had virtually no effect on drinking behaviours. The inverse association between smoking and drinking outcome observed here indicates that non-smokers may be more successful to attain alcohol abstinence than smokers do. However, this association does not imply per se that smoking triggers alcohol consumption, since it can also mean that alcohol consumption promotes smoking.

CONCLUSIONS

It is concluded that (continued) tobacco smoking may have a negative moderating effect on the treatment outcome of AUD treatments. To optimize treatment outcome of AUD one may consider informing and counselling patients with AUD about the risks of smoking for treatment outcomes and offering support for smoking cessation.

The Role of Tobacco Smoking in the Efficacy of Brief Alcohol Intervention: Results from a Randomized Controlled Trial

This study investigated whether tobacco smoking affected outcomes of brief alcohol interventions (BAIs) in at-risk alcohol-drinking general hospital patients. Between 2011 and 2012 among patients aged 18−64 years, 961 patients were allocated to in-person counseling (PE), computer-based BAI containing computer-generated individual feedback letters (CO), and assessment only. PE and CO included contacts at baseline, 1, and 3 months. After 6, 12, 18, and 24 months, self-reported reduction of alcohol use per day was assessed as an outcome. By using latent growth curve models, self-reported smoking status, and number of cigarettes per day were tested as moderators. In PE and CO, alcohol use was reduced independently of smoking status (IRRs ≤ 0.61, ps < 0.005). At month 24, neither smoking status nor number of cigarettes per day moderated the efficacy of PE (IRR = 0.69, ps > 0.05) and CO (IRR = 0.85, ps > 0.05). Up to month 12, among persons smoking ≤ 19 cigarettes per day, the efficacy of CO increased with an increasing number of cigarettes (ps < 0.05). After 24 months, the efficacy of PE and CO that have been shown to reduce drinking did not differ by smoking status or number of cigarettes per day. Findings indicate that efficacy may differ by the number of cigarettes in the short term.

Smoking among inpatients in treatment for substance use disorders: prevalence and effect on mental health and quality of life

BACKGROUND

Smoking is still prevalent among people with substance use disorders. The objective of this study was to investigate the prevalence of smoking among patients in treatment for substance use disorders and to analyze the effect of smoking both at baseline and follow-up on drop-out, mental health and quality of life.

METHODS

One hundred and twenty-eight inpatients (26% female), mainly with alcohol use disorder, staying at three different rehabilitation clinics in Eastern Norway, were interviewed at admission, and at 6 weeks and 6 months follow-up. The interview contained mental health-related problems, trauma, questions on alcohol and other substances and quality of life. Non-parametric tests were used to test group differences and unadjusted and adjusted linear regression to test the associations between smoking and the main outcome variables, while logistic regression was used to test the association between smoking and drop-out.

RESULTS

At admission, 75% were daily smokers. Compared to non-smokers at baseline, the smokers had higher drop-out rates (37% vs. 13%), more mental distress, and lower quality of life from baseline up to 6 months follow-up. Those quitting smoking while admitted improved in mental distress and quality of life at the same rate as non-smokers. Alcohol-related factors did not differ between smokers and non-smokers.

CONCLUSIONS

Smoking was associated with mental distress, quality of life and treatment drop-out among patients in primary alcohol use disorder treatment. The results indicate that smoking cessation should be recommended as an integral part of alcohol use treatment both before and during inpatient treatment to reduce drop-out.

Incidence of and Risk Factors for Alcohol Relapse After Liver Transplantation for Alcoholic Liver Disease: Comparison Between Deceased Donor and Living Donor Liver Transplantation

BACKGROUND

There are controversies over whether patients with alcohol-related liver disease (ALD) should follow the "6-month abstinence rule" before undergoing liver transplantation (LT), especially in case of living donor LT (LDLT). We analyzed the risk of alcohol relapse among ALD patients who received LT according to donor types and abstinence period before LT.

METHODS

A total of 129 patients (mean 50.7 ± 9.2 years, male 78.3%) who underwent LT between January 2000 and July 2017 for ALD at Samsung Medical Center, Seoul, Korea, were analyzed. Alcohol relapse was defined as any use of alcohol after LT.

RESULTS

The alcohol relapse rate was lower in LDLT recipients compared with that in DDLT recipients (13.9% vs. 31.7% at 3 years, P = 0.013). DDLT recipient, short abstinence period (< 6 months), and current smoking status were factors associated with alcohol relapse. The alcohol relapse rate was highest (54.5% at 3 years) for current smokers without 6-month sobriety who received DDLT, and it was lowest for never/ex-smoker with 6-month sobriety who received LDLT (4.3% at 3 years). For LDLT recipients, the alcohol relapse rate was not different according to abstinence period (17.7% vs. 11.6% at 3 years for short abstinent period < 3 months vs. ≥ 3 months, P = 0.92), but it was higher for current smokers compared with that for non/ex-smokers (22.4% vs. 5.8% at 3 years, P = 0.05).

CONCLUSION

When considering LDLT for ALD, sobriety period may not be an absolute contraindication as abstinence period showed a weak association with alcohol relapse. Smokers need careful attention for alcohol relapse.

Predicting relapse after alcohol use disorder treatment in a high-risk cohort: The roles of anhedonia and smoking

On average, two-thirds of individuals treated for alcohol use disorder (AUD) relapse within six months. There is a critical need to identify modifiable risk factors associated with relapse that can be addressed during AUD treatment. Candidate factors include mood disorders and cigarette smoking, which frequently co-occur with AUD. We predicted that co-occurrence of mood disorders, cigarette smoking, and other modifiable conditions will predict relapse within six months of AUD treatment. Ninety-five Veterans, 23-91 years old, completed assessments of multiple characteristics including demographic information, co-occurring psychiatric disorders, and medical conditions during residential treatment for AUD. Participants' alcohol consumption was monitored over six months after participation. Logistic regression was used to determine if, mood disorders, cigarette smoking status, alcohol consumption, educational level, and comorbid general medical conditions are associated with relapse after AUD treatment. Sixty-nine percent of Veterans (n = 66) relapsed within six months of study while 31% remained abstinent (n = 29). While education, comorbid general medical conditions, and mood disorder diagnoses were not predictors of relapse, Veterans with greater symptoms of anhedonia, active smokers, and fewer days of abstinence prior to treatment showed significantly greater odds for relapse within six months. Anhedonia and cigarette smoking are modifiable risk factors, and effective treatment of underlying anhedonic symptoms and implementation of smoking cessation concurrent with AUD-focused interventions may decrease risk of relapse.

An examination of factors associated with tobacco smoking amongst patients presenting with deliberate self-poisoning

BACKGROUND

Understand factors related to related to tobacco smoking amongst individuals who present with deliberate self-harm is important. This article explores the relationship between tobacco use with mental health diagnoses and substance use in a cohort of overdose admissions.

METHODS

Secondary analysis of an existing health service database with 7133 patients admitted for deliberate self-poisonings from 1997 to 2013 was conducted. A data collection form was used on admission to capture information on patient demographics, drugs ingested, use of drugs of misuse, regular medications and management and complications of poisoning. The data was analysed using a multiple logistic regression model.

RESULTS

Within a deliberate self-poisoning population, those diagnosed with: an amphetamine substance use disorder (OR = 1.84, p < .001), alcohol use disorder (OR = 1.68, p < .001), other substance use disorder (OR = 1.77, p < .001), psychotic diagnoses (OR = 1.17, p = .032), or had a history of self-harm (OR = 1.15, p = .011) were more likely to be a current tobacco smoker. Those who were older (OR = 0.99, p < .001) or diagnosed with a mood disorder (OR = 0.87, p = .018) were less likely to smoke tobacco.

LIMITATIONS

The study was unable to differentiate between suicide attempts and self-harm self-poisonings.

CONCLUSIONS

Among a deliberate self-poisoning population those who were younger, diagnosed with a variety of substance use disorders, or had a history of previous self-poisoning were more likely to use tobacco. Those with a mood disorder were less likely to smoke tobacco.

Alcohol use disorder relapse factors: A systematic review

A relapsing-remitting course is very common in patients with an Alcohol Use Disorder (AUD). Understanding the determinants associated with alcohol resumption remains a formidable task. This paper examines relapse determinants based on a systematic review of recent alcohol literature (2000-2019). Relevant databases were consulted for articles that contained information about specific relapse determinants and reported statistical significance of each relapse determinant in predicting relapse. Relapse was broadly defined based on the characterization in the included articles. From the initial identified 4613 papers, a total of 321 articles were included. Results encompass multiple relapse determinants, which were ordered according to biopsychosocial and spiritual categories, and presented, using a descriptive methodology. Psychiatric co-morbidity, AUD severity, craving, use of other substances, health and social factors were consistently significantly associated with AUD relapse. Conversely, supportive social network factors, self efficacy, and factors related to purpose and meaning in life, were protective against AUD relapse. Despite heterogeneity in different methods, measures, and sample characteristics, these findings may contribute to a better therapeutic understanding in which specific factors are associated with relapse and those that prevent relapse. Such factors may have a role in a personalized medicine framework to improve patient outcomes.

Nicotine-Use/Smoking Is Associated with the Efficacy of Naltrexone in the Treatment of Alcohol Dependence

BACKGROUND

The opioid antagonist naltrexone is not efficacious for every alcohol treatment seeker. However, various individual factors, such as genetic differences and nicotine-use/smoking status, have been suggested as predictors of naltrexone response. In a randomized clinical trial, we previously reported that nicotine-use/smoking status might be a stronger predictor of naltrexone efficacy than OPRM1 A118G single nucleotide polymorphism (SNP) genotype. In this report, we further characterize the nicotine-users in that trial, examine other drinking outcomes, examine the influence of smoking change on naltrexone effects on drinking, and validate the result in smokers with disialo carbohydrate-deficient transferrin (%dCDT) change as an independent biomarker of response.

METHODS

Individuals (n = 146) meeting DSM-IV criteria for alcohol dependence who were genotyped for the OPRM1 A118G SNP and who did, or did not, use nicotine/cigarettes were randomized, in a balanced fashion, to naltrexone (50 mg/d) or placebo and provided medical management (MM) over a 16-week clinical trial. Alcohol use and smoking during the trial were assessed and analyzed.

RESULTS

Nicotine-use/smoking status significantly interacted with medication in reducing percent heavy drinking days (PHDD) during the trial (p = 0.003), such that nicotine-users/smokers showed significantly lower PHDD on naltrexone versus placebo (p = 0.0001, Cohen's d = 0.89), while nonusers showed no significant difference between naltrexone and placebo (p = 0.95, Cohen's d = 0.02). Similar effects were shown for drinks per day and percent days drinking. The superiority of naltrexone over placebo on PHDD reduction in nicotine-users/smokers was confirmed with %dCDT (Cohen's d range 0.3 to 0.9 over the study). Naltrexone did not significantly change cigarette use in smokers, and change in use did not influence naltrexone's effect on PHDD.

CONCLUSIONS

These data confirm past findings that naltrexone is more efficacious in those who use nicotine/cigarettes. Compared to previous work on the OPRM1 A118G SNP, it appears that nicotine-use might be a more salient predictor of naltrexone treatment response. While naltrexone did not change cigarette use during the study, and smoking change was not related to alcohol reduction, it should be noted that participants were not seeking smoking cessation and MM did not address this issue.